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On the Third Hand: Surprise

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The story The New York Times published over the weekend to rattle the U.S. health policy agenda was about a neck surgery patient who discovered charges from providers he had never heard of when he looked at his bills.

Elisabeth Rosenthal noted that many patients get bills from mystery providers who swoop in at the last minute to pig out on out-of-network payment gravy.

On the one hand: Hey, Elisabeth Rosenthal, welcome to the real world.

“Health policy groups,” “patient advocacy groups” and “consumer groups” in general seem to operate under the general assumption that insurance companies are heartless crooks and that doctors and hospitals are saintly.

But I think most of us who have entered a hospital for anything, even having a baby, in modern times, have discovered that, in practice, being a good health care consumer in a hospital is absolutely impossible. When I had a baby, I went to an in-network hospital, I had an in-network Ob/Gyn, and I had a printed list of anesthesiologists in the hospital who were in my network. I knew all about balance billing. I had interviewed all sorts of experts about balance billing. I had no more actual ability to avoid seeing out-of-network providers in the operating room than I had of flying out the window and circling the spire of the Empire State Building.

The only reason I avoided huge amounts of balance billing is that, for some reason, due to state law, provider-insurer negotiations, or provider niceness, the providers accepted the insurer’s views on what the reasonable and customary charges ought to be.

In another case, I went in for a simple checkup, ended up with a $400 sick visit bill, and got out of that bill only by carrying on in such a way that I’m a little afraid to ever get health care ever again.

But, on the other hand, it’s important to think about this sort of situation in a comprehensive way and not just go out for blood because the “surprise anesthesiologist bill” is such a great, infuriating creator of wrath. If and when doctors involved in complicated procedures have a genuine need for help, even out-of-network help, simply forbidding that without thinking hard about extenuating circumstances may be a health insurance-wise, disability insurance (or life insurance) foolish thing to do.

I have a middle-aged relative (details changed to protect privacy) — one who told me why she thought long-term care insurance (LTCI) was a bad value — who had “routine neck surgery,” and then needed long-term care for the rest of her life. I have no idea whether inviting an out-of-network neurologist into the operating room would have helped her, but, if an out-of-network neurologist could have prevented the actual outcome, that would have been well worth a $50,000 out-of-network consulting fee.

On the third hand, of course, most of those surprise out-of-network bills are just the result of providers using teamwork to shaft the rest of us. But, in many cases, the surprise provider bill is probably the result of cost shifting. Providers are severely over-billing some patients to make up for the Medicare patients, Medicaid patients and completely uninsured patients who pay little or nothing.

To some extent, the Patient Protection and Affordable Care Act (PPACA) may make the pressure to use whatever remaining methods there are to overbill even worse, by encouraging doctors and hospitals to accept unsustainably low fees to get into accountable care organization networks or other narrow networks. 

One cure may be the rise of “self-pay,” “cash only” practices. When patients and providers negotiate a price directly with each other, without insurance company or government plan involvement, maybe that price has some kind of interesting relationship with what providing the care really costs.

Maybe another cure could be that policymakers, insurers, brokers and employers have to take an interest in provider sustainability. We want health care to be cheap. We also want it to exist, and to be paid for in an honest way. Maybe we have to figure out how to tell the difference between the kind of fraud that makes people rich and the kind that desperate, failing businesses use to keep the doors open another day.


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